It’s that time of year again, namely flu vaccine time. My very own cancer institute will be offering the flu vaccine for its staff beginning October 1, and I plan on getting mine just as soon as I get back from the American College of Surgeons Clinical Congress in Chicago early next week. In the meantime, it’s always great to read Mark Crislip’s take on the yearly flu vaccine kerfuffle, particularly this part:

I have little (actually none) respect for HCW’s [health care workers] who do not get vaccinated. We have a professional and moral obligation to place our patients first. I think those who do not get vaccinated, except for a minority with a valid allergy, are dumb asses.

Preach it, Dr. Crislip!

However, this time of year is also a vaccine time of year for another reason (well, actually it was about a month ago). That’s because in late August or early September, depending on your state, the little kiddies (and not-so-little kiddies) return to school and therefore have to be up to date on their required vaccines or face not being able to go to school. No wonder the antivaccine movement goes nuts this time of the year, given the double whammy of antivaccine parents trying to avoid vaccinating their children before going to school by hook or by crook and the yearly promotion of flu vaccines and mandates that health care workers get them. (For the record, my cancer center requires it, and if there’s one thing the administration of my hospital has done that I fully support it’s the yearly vaccine requirement. We’re a cancer hospital, fer cryin’ out loud, and we have lots of immunosuppressed patients that we take care of!) The only other time of year when antivaccinationists are even close to this actively ridiculous is every April, which is Autism Awareness Month, when they start trying to tar attempts to highlight autism and autism research with demands that antivaccine pseudoscience be thrown into the mix like the proverbial cow pie added to the apple pie.

Since Mark’s already covered the flu vaccine so well, let’s talk about the topic of nonmedical exemptions to school vaccine mandates. This topic came up when I noticed that the bloggers and denizens of that most wretched hive of antivaccine scum and quackery, Age of Autism, have swarmed over to a news story about how Washington State has made it harder for parents to obtain nonmedical exemptions to school vaccine requirements:

Washington State is home to Bill and Melinda Gates, champions of childhood vaccines across the globe. Its university boasts cutting-edge vaccine research. But when it comes to getting children immunized, until recently, the state was dead last.

“You think we’re a cut above the rest,” said Dr. Maxine Hayes, state health officer for Washington’s Department of Health, “but there’s something in this culture out West. It’s a sort of defiance. A distrust of the government.”

The share of kindergartners whose parents opted out of state immunization requirements more than doubled in the decade that ended in 2008, peaking at 7.6 percent in the 2008-9 school year, according to the state’s Health Department, raising alarm among public health experts. But last year, the Legislature adopted a law that makes it harder for parents to avoid getting their children vaccinated, by requiring them to get a doctor’s signature if they wish to do so. Since then, the opt-out rate has fallen fast, by a quarter, setting an example for other states with easy policies.

Good going, Washington! It’s about time. Over the last several years, Washington has become known as a state with such low vaccine uptake rates that it was fast on its way to becoming the capital of vaccine-preventable diseases; that is, if it could beat California, which is currently considering its own similar bill (AB 2109) that would require a doctor’s signature on vaccine exemptions certifying that the parents have been counseled and given true informed consent about the risks of not vaccinating. (This is, of course, in contrast to the misinformed consent, in which vaccines are blamed for autism, asthma, autoimmune diseases, sudden infant death syndrome, and more by antivaccinationists in order to provide a false picture of the balance of risks and benefits of vaccines that make vaccines look like the riskiest thing you can do to your child. Such are the lies of the antivaccine movement.) Indeed, Rob Schneider, of all people, has arisen as a new celebrity leader of the antivaccine resistance to AB 2109 on par with the idiocy of Jenny McCarthy on vaccines, even going so far as to claim vaccines are a violation of the Nuremberg Code.

In the U.S., certain vaccines are required before children can enter school, and there is a wide range of how tightly these vaccine mandates are enforced. In two states (West Virginia and Mississippi), for instance, no non-medical exemptions are permitted: only children with legitimate medical reasons can be exempted from the school vaccine mandate and then only with a letter from their doctor attesting to a condition or diagnosis that is a contraindication to vaccination. The other 48 states allow some form of non-medical exemptions to vaccine mandates. Twenty of these states allow “philosphical” or “personal belief” exemptions.

Non-medical exemptions are a delicate topic. On the one hand, there’s overwhelming evidence that such exemptions lead to more children remaining unvaccinated and more children at risk for potentially deadly vaccine-preventable diseases, thus degrading herd immunity and contributing to outbreaks. In the U.K., the MMR scare has been particularly devastating, leading to a massive resurgence of the measles over the last 14 years, as MMR uptake fell to as low as 50% in some parts of London. On the other hand, in the U.S. in particular, there is very much a theme of extreme resistance to being told what to do by the government. We’re actually seeing that in play right now, as I believe that much of the resistance to the Patient Protection and Affordable Care Act (colloquially known as “Obamacare”) derives from just that resistance.

Which brings us to the letter in the NEJM that I mentioned above and that also happens to be mentioned in the NYT article. It’s unusual for a letter to a journal, even the NEJM, to make the news, but this one, by Saad B. Omer, M.B., B.S., Ph.D., Jennifer L. Richards, M.P.H., Michelle Ward, A.B., and Robert A. Bednarczyk, Ph.D. from Emory University, entitled Vaccination Policies and Rates of Exemption from Immunization, 2005–2011, was mentioned in the NYT article, and it was featured on Good Morning America:

The report states:

An increasing number of parents are getting state approval to allow their children to opt out of school-mandated vaccinations for non-medical reasons, according to a new analysis published Wednesday.

Dr. Saad Omer, author of the correspondence published in the New England Journal of Medicine, warned that this trend is leaving large populations of children at risk for developing potentially deadly illnesses that haven’t been seen in the United States in many years.

“Rates of exemption are substantially higher today than several years ago,” said Omer, assistant professor of global health, epidemiology and pediatrics at Emory University in Atlanta. “Previously, rates were only rising in states with easy exemption policies, but now they are even rising in states that make it more difficult.”

Basically, what Omer et al. found is what I like to call a “Well, duh!” result, but sometimes “Well, duh!” results are important. In this case, Omer’s results were not the least bit unexpected, but the reason for him to do the study is (1) to determine whether “common wisdom” about vaccine exemptions is correct (it turns out that it is) and (2) to quantify the effect, which is what Omer et al. tried to do. Common sense and an understanding of human nature tell us that if something’s easy to get more people will take it and that if something’s harder to get fewer people will take it.

What Omer et al. found is that during the study period, nonmedical vaccine exemptions were 2.54 times as high in states that allowed philosophical exemptions as they were in states that allowed only religious exemptions. Omer et al. then categorized states allowing nonmedical exemptions by the degree of difficulty in obtaining such exemptions. Categories of difficulty were based on several factors, including whether completion of a standard form was permissible, as opposed to a letter; where the parent has to get the form (school versus health department); whether the form needed to be notarized; whether a physician needs to sign it; and the like. The results were, as I pointed out, predictable:

During the study period, unadjusted rates of nonmedical exemptions in states with easy exemption policies were 2.31 times as high as rates in states with difficult exemption policies (IRR, 2.31; 95% CI, 1.39 to 3.85). By 2011, the nonmedical exemption rate in states with easy exemption criteria increased to 3.3%, an average annual increase of 13% (IRR for change per year, 1.13; 95% CI, 1.05 to 1.21) (Figure 1, and Table S1 in the Supplementary Appendix). In contrast, nonmedical exemption rates in states with difficult exemption criteria increased by 8% annually to 1.3% in 2011 (IRR for change per year, 1.08; 95% CI, 1.02 to 1.14). In states with exemption criteria of medium difficulty, rates increased by 18% annually to 2.0% in 2011 (IRR for change per year, 1.18; 95% CI, 1.10 to 1.26). For all analyses, adjusted results were qualitatively similar to unadjusted results.

In other words, as one would expect, the easier it is to get nonmedical exemptions from school vaccine mandates, the more parents there will be who will take them. Citing their previous work that examined exemptions from 1991 to 2004, in which they found an increase in nonmedical exemptions only in states where philosophical exemptions were permitted and comparing their previous results to their current results, Omer et al. found a troubling trend. Even in the states with philosophical exemptions, the rate of increase in nonmedical exemptions was less in the preceding period than it was from 2005 to 2011. Worse still, the rate of increase of nonmedical exemptions appears to be accelerating and spreading to states with only religious exemptions. There are potentially disastrous consequences if this trend continues unabated. There is, after all, evidence that lax exemptions policies correlate with a higher incidence of pertussis and measles.

So what is the answer? From a strictly scientific standpoint, the answer is easy. Get rid of nonmedical exemptions. However, this is a situation where the ideal could well be the enemy of the possible. On a strictly political basis, even a lot of people who accept that vaccines are safe and effective and know that the only thing nonmedical exemptions achieve is to degrade herd immunity and increase the likelihood of outbreaks of vaccine-preventable diseases have a bit of a problem with mandates that don’t allow for religious and/or philosophical nonmedical exemptions. In a nation in which the elimination of all nonmedical exemptions to school vaccine mandates will not be possible for the foreseeable future, the next best thing is to make exemptions harder to get. However, even this tactic can run into thorny issues, particularly religious exemptions, if the state tries to make sincerity of belief a criterion.

Personally, I reluctantly accept that eliminating nonmedical exemptions is politically toxic. Recent experience in Vermont, California, and even Washington tell us this. Indeed, in California, an unholy alliance of antivaccinationists and Tea Party activists put up a strong fight against AB 2109, which only sought to make it harder to obtain nonmedical exemptions. Even now, although the bill passed both houses of the California legislature and is sitting on Governor Jerry Brown’s desk for his signature, he hasn’t signed it yet. It is not clear why, but there is considerable pressure on him from antivaccinationists teaming up with “health freedom” activists to veto the bill. Given these difficulties in passing bills that go even a short distance in making nonmedical exemptions easier than the parent’s just signing a form, tightening up the process for obtaining nonmedical exemptions is at this time probably the best that we can hope for.

Unfortunately, the antivaccine movement has been very successful in framing the issue of nonmedical exemptions to vaccine mandates not as an issue of medicine and protecting children, but rather as an issue of “parental rights,” in which an overweening state is portrayed as overstepping its power, crushing the rights of parents, and forcing children to be vaccinated. (One can almost hear the jackboots marching, given the liberal use of overblown and historically ignorant Nazi analogies by opponents of such bills.) Perhaps that’s one reason why antivaccine views tend to appeal to Tea Party activists as much as they do to crunchy, pharma-hating people at the opposite end of the political spectrum. Amusingly (well, in some ways), antivaccine activists will even co-opt the political language used so frequently in the 2012 election, as when Barbara Loe Fisher actually had the temerity to claim that those promoting tightening up or eliminating nonmedical exemptions based on personal belief are “waging class warfare.” I kid you not. To Fisher, it’s class warfare against the well-off:

A hilarious exerpt:

It is getting uglier and uglier out there, as angry, frustrated doctors inside and outside of government work overtime to foster fear and hatred of parents making conscious vaccine choices for their children. The latest political dirty trick is to brand parents, who send their children to private schools, as selfish and a threat to their communities because some private schools have higher vaccine exemption rates.

It is, of course, true that many private schools have higher vaccine exemption rates. Waldorf schools come to mind, given that the entire philosophy upon which they are founded includes a medical philosophy that explicitly rejects vaccines. It is also true that many antivaccine parents are well-off and highly educated. It is, as I’ve pointed out before, the arrogance of ignorance, and their higher level of education makes them better at motivated reasoning, resulting in what is sometimes called the “smart idiot” effect. Apparently, to Fisher, pointing that out is “class warfare”:

When doctors politicize vaccine exemptions in order to engage in class warfare, they are crossing a line that reveals more about who they are than the families they are trying to stereotype and marginalize. Dr. Pan, who has assumed the mantle of lawmaker, and Dr. Omer, who enjoys six federal vaccine research grants funded by the CDC or NIH, [12] and Dr. Halsey, who has funding from SmithKline Beecham and the Gates foundation,[13] likely are not struggling to pay the rent or pay for groceries.

Ah, yes. The pharma shill gambit coupled with specious accusations of class warfare. Fisher is nothing if not consistent.

Finally, it’s impossible for me to discuss this issue without addressing the elephant in the room: religious exemptions.

In the states that allow only religious exemptions, religion is being privileged above all other belief systems in being the only legally acceptable basis for parents to opt out of vaccine mandates. That’s why I’m of the opinion (which has on occasion gotten me into little tiffs with fellow travelers in the battle against antivaccine lunacy) that, if a state is going to permit nonmedical vaccines, it should allow both religious and philosphical exemptions. To do otherwise is to give undue privilege to religious belief over nonreligious belief and discriminates against nonbelievers. Antivaccinationists take advantage of religious exemptions anyway, promoting them and even telling parents how to lie about their religious beliefs in states that only allow religious exemptions. So, if a state is going to allow nonmedical exemptions, it should allow personal belief exemptions for any reason or not allow them at all (preferably not at all).

Unfortunately, it is almost certainly completely unrealistic to get rid of philosophical exemptions (to me that includes religious exemptions) to vaccine mandates altogether. The reason is that, in the U.S. at least, there is a long history of being wary of government mandates, particularly in health care. As I’ve said before, compulsory “anything” laws tend to be very politically unpopular, as has been so thoroughly demonstrated by the political resistance to the Patient Protection and Affordable Care Act (or, as its opponents sneeringly refer to it, Obamacare). Vaccine mandates that go too far politically, as scientifically justified as they may be, have the potential to provoke major backlashes against vaccine programs, as compulsory vaccination laws for all children did in the 1800s in England, Europe, and the U.S. Going too far, even for public health, risks a very real backlash, and even supporters of mass vaccination campaigns (myself included) worry about government overreach and intrusion into personal medical issues.

In this political climate, the best we can hope for is probably to limit nonmedical exemptions as much as will be tolerated and, at the very least, make them harder to get, which is why I tend to think trying to eliminate them altogether is probably a lost cause that takes up energy that could be better used for other aspects of what is necessary to promote vaccine science. It’s true that overall the national vaccine uptake rate is high and nonmedical exemption rate low, but that’s changing. The increase in nonmedical exemptions is concerning, and in some areas it’s leading to pockets of vaccine resistance such as Vashon Island in Washington, where the exemption rate approaches 25%.

In the meantime, laws should be passed that make nonmedical exemptions rare by requiring parents to do more than just sign a form. It is a battle that was recently won in Washington, is still being bitterly fought in New Jersey and in California, where a concerted campaign is being waged to persuade Governor Jerry Brown to veto AB 2109, but lost in Vermont.

Posted by David Gorski

Dr. Gorski's full information can be found here, along with information for patients. David H. Gorski, MD, PhD, FACS is a surgical oncologist at the Barbara Ann Karmanos Cancer Institute specializing in breast cancer surgery, where he also serves as the American College of Surgeons Committee on Cancer Liaison Physician as well as an Associate Professor of Surgery and member of the faculty of the Graduate Program in Cancer Biology at Wayne State University. If you are a potential patient and found this page through a Google search, please check out Dr. Gorski's biographical information, disclaimers regarding his writings, and notice to patients here.